Free CHSP Compliance and Accreditation Questions and Answers 1 — Questions and Answers
Question 1: A hospital is seeking accreditation from an organization that uniquely integrates ISO 9001 quality management principles with its standards and conducts annual on-site surveys. Which accrediting body would the hospital be engaging with?
- The Joint Commission (TJC)
- DNV (Det Norske Veritas) (Correct answer)
- Centers for Medicare & Medicaid Services (CMS)
- Occupational Safety and Health Administration (OSHA)
Correct answer: DNV (Det Norske Veritas)
DNV is distinct among healthcare accrediting bodies for its integration of the ISO 9001 Quality Management System into its accreditation process. This approach combines CMS Conditions of Participation with a quality improvement framework. DNV also conducts annual on-site surveys, which contrasts with The Joint Commission's typical survey cycle.
Question 2: As part of its emergency management program, a hospital is reviewing the CMS Conditions of Participation (CoP) for Emergency Preparedness. Which of the following is a core element required by this rule?
- Conducting a community-based disaster drill at least once every five years.
- Developing a communication plan to coordinate patient care with other providers and emergency systems. (Correct answer)
- Limiting emergency training to clinical staff and first responders only.
- Mandating that the emergency plan be approved by the Federal Emergency Management Agency (FEMA).
Correct answer: Developing a communication plan to coordinate patient care with other providers and emergency systems.
The CMS Emergency Preparedness Rule requires participating providers, including hospitals, to develop and maintain a program based on four core elements. One of these is a communication plan to ensure patient care is well-coordinated with other healthcare providers, as well as with federal, state, and local emergency systems, during a disaster.
Question 3: A safety professional is auditing compliance with The Joint Commission's National Patient Safety Goals (NPSGs). Which of the following initiatives directly addresses a 2025 NPSG?
- Implementing a new process for reducing the risk of healthcare-associated infections. (Correct answer)
- Reducing overhead pages to create a quieter hospital environment.
- Offering expanded meal options on the patient menu.
- Upgrading the hospital's parking garage lighting system.
Correct answer: Implementing a new process for reducing the risk of healthcare-associated infections.
One of the key National Patient Safety Goals for 2025 is the prevention of infection. This goal specifically requires organizations to use established guidelines, such as those from the CDC or WHO, for hand hygiene to reduce the risk of healthcare-associated infections (HAIs). The other options, while potentially beneficial, do not directly align with a specific NPSG.
Question 4: According to the NFPA 101, Life Safety Code®, what is the primary determinant for classifying a facility as a 'Health Care Occupancy' versus an 'Ambulatory Health Care Occupancy'?
- The number of operating rooms in the facility.
- The total square footage of the building.
- Whether four or more patients are treated on an inpatient basis. (Correct answer)
- The presence of a 24-hour emergency department.
Correct answer: Whether four or more patients are treated on an inpatient basis.
NFPA 101 defines a 'Health Care Occupancy' as a facility used to provide treatment or care simultaneously to four or more patients on an inpatient basis, where they are mostly incapable of self-preservation. The key distinction from an 'Ambulatory Health Care Occupancy' is the inpatient status of the patients.
Question 5: A healthcare facility is cited by OSHA for a violation of the 'General Duty Clause'. Which of the following scenarios would MOST likely lead to such a citation?
- Failing to provide annual bloodborne pathogen training to all employees.
- Not having a written Hazard Communication plan available for review.
- Lacking a program to address the recognized hazard of workplace violence. (Correct answer)
- Improperly labeling a secondary container of a cleaning chemical.
Correct answer: Lacking a program to address the recognized hazard of workplace violence.
The General Duty Clause (Section 5(a)(1) of the OSH Act) requires employers to provide a workplace free from recognized hazards that are causing or are likely to cause death or serious physical harm. Workplace violence is a well-recognized hazard in the healthcare industry. While the other options are violations of specific OSHA standards (e.g., Bloodborne Pathogens, Hazard Communication), a failure to address a known, serious hazard like workplace violence falls under the General Duty Clause when a specific standard does not exist.
Question 6: A hospital surveyor is assessing compliance with The Joint Commission's Universal Protocol for preventing mistakes in surgery. Which of the following is a required step in this protocol?
- Ensuring the patient's family members agree with the procedure.
- Conducting a post-procedure debrief with the surgical team.
- Performing a 'time-out' immediately before starting the procedure. (Correct answer)
- Videotaping the entire surgical procedure for quality review.
Correct answer: Performing a 'time-out' immediately before starting the procedure.
The Universal Protocol has three principal components: a pre-procedure verification process, marking the procedure site, and performing a time-out. The time-out is a critical final step conducted immediately before starting the procedure to confirm the correct patient, procedure, and site.
Free CHSP Compliance and Accreditation Questions and Answers 1
A hospital is seeking accreditation from an organization that uniquely integrates ISO 9001 quality management principles with its standards and conducts annual on-site surveys.
Which accrediting body would the hospital be engaging with?